HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 356 RALEIGH TAVERN LANE 5/19/2020 Commonwealth of Massachusetts
RECEIVED
r City/Town of No. Andover MAY 19 2020
System Pumping Record TOWN OF NORTH ANDOVER
rG^M
Form 4 . , :.
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, /`
14'. x
use only the tab
key to move your Address
cursor-do not No. Andover MA 01845
use the return Cityfrown State Zip Code
key.
2. Syste ner:
rab
c
Name
rmm
Address(if different from location)
Cityrrown State Zip Code
i
Telephone Number 10
B. Pumping Record
1. Date of Pumping Da a 2. Quantity Pumped: o
Gas
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes E�<o If yes, was it cleaned? ❑ Yes 2-No
5. Observed condition of component pumped:
6. S stem Pumped BY:
NNh., � (zV62=
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
20 So. , Br ford A
Z'-� -2
Signature of Haulerlelo'
Date
Signature of Receiving Facility(or attach facility receipt) Date
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